Lehigh Valley Health Network
LVHN Scholarly Works
Department of Medicine
Appearances Can Be Deceiving - Colon Cancer
Mimicking Ileocolitis
Abdul Aleem MD
Lehigh Valley Health Network, [email protected]
Muhammad Qasim MD
Lehigh Valley Health Network, [email protected]
Patrick Hickey DO
Lehigh Valley Health Network, [email protected]
Hiral N. Shah MD
Lehigh Valley Health Network, [email protected]
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Published In/Presented At
Aleem, A. Qasim, M. Hickey, P. Shah, h. (2016,Oct). Appearances Can Be Deceiving - Colon Cancer Mimicking Ileocolitis. Poster
Presented at: PA-ACP Eastern Region Competition, Danville, PA.
This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an
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Appearances Can Be Deceiving - Colon Cancer Mimicking Ileocolitis
Abdul Aleem MD , Muhammad Qasim MD , Patrick Hickey DO and Hiral N. Shah MD
1
1
2
2
Department of Internal Medicine, Department of Gastroenterology, Lehigh Valley Health Network, Allentown, Pennsylvania
1
2
Discussion and Follow-up
Case Presentation
Background
•Colorectal cancer (CRC) is the third most
common non-skin cancer, and the second
1
leading cause of cancer death in the USA.
•The most widely accepted hypotheses for
the origin of CRC are environment-induced
genetic alterations, hereditary predisposition,
or both factors acting together resulting in the
2
unregulated cellular proliferation.
•The disease usually begins as a benign
adenomatous polyp which subsequently
progresses to an advanced adenoma with highgrade dysplasia, and then progresses to an
invasive cancer.3
•Both, the incidence and mortality rates of CRC
have been decreasing in the United States.
•This has been largely attributed to an increase
in CRC screening under the United States
Preventive Services Task Force (USPSTF)
guidelines recommending screening for all
4
adults 50 years or older.
DISCUSSION:
•A 35-year-old Caucasian female with past medical history of opioid abuse presented to the Emergency Department with complaints of
nausea, vomiting and cramping abdominal pain of four days’ duration.
•Initial Abdominal CT (Image 1) showed circumferential thickening of the terminal ileum and the cecum suggesting active enteritis.
•Family history was negative for Inflammatory Bowel Disease or Colorectal Cancer.
•ESR was 0 mm/hr, C-Reactive Protein was elevated at 22.5 mg/L and Stool PCR for Bacterial pathogens was negative.
•She was treated empirically for presumed infectious enteritis with intravenous cefazolin and metronidazole with some improvement. She
was discharged on oral antibiotics with planned outpatient evaluation for inflammatory bowel disease (IBD).
•She was readmitted with recurrent symptoms of nausea and vomiting one week after discharge. The patient also noted that her
abdominal pain had become more sharp.
•A repeat CT Abdomen (Image 2) again showed active bowel inflammation with luminal narrowing.
•At this point a fecal calprotectin ordered on her first admission was elevated at 571 ug/g.
•She was treated for presumed recurrent infection and probable acute Crohn Disease with IV ciprofloxacin, metronidazole, and
methylprednisolone at the recommendation of Gastroenterology.
•Despite three days of treatment with IV antibiotics and steroids, her symptoms failed to improve.Subsequently she developed a new-onset
inability to pass stool or flatus.
•An abdominal obstruction series (Image 3) showed a partial small bowel obstruction. This failed to improve with conservative measures.
•The patient was taken for an exploratory laparotomy which revealed an obstructing ascending colonic mass (Image 4), and a
hemicolectomy was performed.
•Pathology of the excised colonic mass (Image 5) confirmed stage IIA colonic adenocarcinoma.
•The incidence rates of CRC is increasing in young adults and declining in adults
older than 50 years.6
•A recent study by Bailey et. al using the Surveillance, Epidemiology and End Results
(SEER) databases showed an increase in the incidence of CRC in patients 20 to
6
49 years old, with the most significant increase in patients aged between 20 to 34.
•The majority of CRC cases in young adults are sporadic in nature, and is likely
due to behavioral and environmental causes, however the exact etiology remains
7
unclear.
•Young adults with CRC often present with symptoms (abdominal pain, rectal
bleeding, weight loss) and diagnosis is often delayed due to physicians attributing
symptoms to diagnoses other than CRC. Hence, it is always necessary to maintain
7
a high index of suspicion.
•The diagnostic challenge in our case was the elevated C-Reactive protein, elevated
fecal calprotectin, and features of inflammation on imaging that appeared more
consistent with inflammatory bowel disease.
FOLLOW-UP:
•The patient tolerated her procedure well and had no issues in the post-operative
period.
•She was treated with single agent chemotherapy capecitabine and is currently
undergoing adjuvant chemotherapy with 5-flourouracil.
•She has declined genetic counseling and testing.
REFERENCES:
•The USPSTF also recommends screening for
CRC in high-risk patients (those with a history
of familial polyposis, hereditary nonpolyposis
5
CRC, ulcerative colitis) prior to 50 years of age.
1.Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64:9–29.
2.Theodore G. Krontiris, M.D., Ph.D. N Engl J Med 1983; 309:404-409.
3.Kinzler KW, Vogelstein B. Colorectal tumors. In: Vogelstein B, Kinzler KW, eds. The genetic basis of human cancer. 2nd ed. New York: McGraw-Hill, 2002:583-612.
4.Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30.
5.US Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137(2):129-131.
6.Christina E. Bailey, MD, MSCI; Chung-Yuan Hu, MPH, PhD; Y. Nancy You, MD, MHSc; Brian K. Bednarski, MD; Miguel A. Rodriguez-Bigas, MD; John M. Skibber, MD; Scott
B. Cantor, PhD; George J. Chang, MD, MS Increasing Disparities in the Age-Related Incidences of Colon and Rectal Cancers in the United States, 1975-2010 JAMA Surg.
2015;150(1):17-22.
7.Inra, J.A. & Syngal, S. Dig Dis Sci (2015) 60: 722.
Table 1. Risk Factors for the Development of Colon Cancer
African American Race
Tobacco Use
Inflammatory Bowel Disease
Gender-Male
Family History of CRC
Obesity
Hereditary CRC Syndromes
Consumption of Red and Processed Meat
Image1. Initial Abdominal CT:
Circumferential thickening of the
terminal ileum and cecum, likely
indicative of active enteritis.
Image 2. Repeat Abdominal CT:
Active bowel inflammation with
luminal narrowing affecting the
terminal ileum and mid-ascending
colon.
Image 3. Abdominal Obstruction Image 4. Gross specimen of the
Series: Dilated loops of small
obstructing ascending colon mass.
bowel within the left and central
abdomen with an abrupt caliber
change in the right lower
abdomen compatible with small
bowel obstruction.
Image 5. Histopathologic
specimen showing the
characteristic findings of lowgrade adenocarcinoma of the
ascending colon.
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